Note for Jane Doe on 02/10/2005 - Chart 3642 Consultation was requested by Dr. Smith Chief Complaint (1/1): This 31 year old Caucasian female presents today for evaluation of chest pain. Chest pains HPI: This 31 year old Caucasian female has experienced chest pains for 60 minutes. The patient has a history of cardiac disease which is detailed in the PMH. She describes the discomfort as a heavy "weight like" sensation in the left precordial region of the chest. She gets two to four attacks per day. It usually comes on while she is walking up stairs and exercising. The pain does radiate to the jaw and down the left arm. The episodes usually last approximately 12 minutes and are relieved by rest. The chest pain is frequently associated with shortness of breath and diaphoresis. The patient has not sought medical care for this problem. Smoking: yes. 5 packs per day, 12 years. Cola and Coffee 5 cups of coffee and 3 cans of soda per day. Allergies: No known medical allergies. Medication History: Patient is currently using Vicodin 325 mg-10 mg tablet (One or two pills q6h prn) usage started on 09/07/2004. PMH: Past medical history unremarkable. PSH: No previous surgeries. Family History: Unremarkable. Social History: Patient admits tobacco use. She relates a smoking history of 10 pack years, Patient admits caffeine use. She consumes 6-10 servings per day, Patient denies alcohol use, Patient denies STD history, Patient denies illegal drug use. Review of Systems: Respiratory: (+) dyspnea, Psychiatric: (+) unremarkable, Neurological: (+) unremarkable, Musculoskeletal: (+) unremarkable, Integumentary: (+) unremarkable, Hematologic / Lymphatic: (+) unremarkable, Genitourinary: (+) unremarkable, Gastrointestinal: (+) unremarkable, Eyes: (+) unremarkable, Endocrine: (+) unusual fatigue, Ears, Nose, Mouth, Throat: (+) unremarkable, Constitutional Symptoms: (+) anxiety, Cardiovascular: (+) chest pain, (+) chest pressure, Allergic / Immunologic: (+) unremarkable. Physical exam: BP Sitting: 180/100 Resp: 27 HR: 114 Temp: 98.6 Height: 5 ft. 4 in. Weight: 226 lbs. BMI: 39 SPO2: 85%Blood pressure: Blood pressure of right arm is 190/102. Patient is alert, pleasant and with good attention to hygiene and body habits. Eye: Pupil exam reveals round and equally reactive to light and accommodation. Conjunctiva and lids reveal no signs or symptoms of infection bilaterally. ENT: Inspection of lips, gums and palate reveals healthy gums, lips and palate pink and moist without lesions. Inspection of oral mucosa reveals no pallor or cyanosis. Neck: Neck supple, trachea midline without adenopathy or crepitance palpable. Jugular veins examination reveals no distention or abnormal waves were noted. Thyroid is smooth and symmetric with no enlargement, tenderness or masses noted. Respiratory: Assessment of respiratory effort reveals increased expiratory effort. Chest is clear to percussion. Lungs clear to auscultation with no rubs noted. Cardiovascular: The apical impulse on heart palpation is located in the left fifth intercostal space in the midclavicular line, no thrill or heaves noted. Heart auscultation reveals rhythm is regular, normal S1 and S2 and no murmurs, gallop, rubs or clicks. Pain located on left upper chest described as heaviness. Carotid pulses are palpated bilaterally and are symmetric, no bruits are auscultated over the carotid arteries. Abdominal aorta is of normal size without presence of systolic bruit. Chest is symmetric, no scars visible, with no port or pacemaker. Pulse exam reveals: Pedal pulses are 4 /4, Left and 3 /4, Right. Right foot and left foot shows evidence of edema +2. No clubbing or cyanosis. Femoral pulses are palpable bilaterally, without bruits. Abdomen: Abdomen soft, non-tender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities with respect to size, tenderness or masses.
Palpation of spleen reveals no abnormalities with respect to size, tenderness or masses. Neurological: Oriented to person, place and time. Mood and affect normal and appropriate to situation. Musculoskeletal: Muscle strength is 5/5 for all groups tested. Gait stable and station mid position and normal. Examination of the back reveals no abnormalities. Skin: Inspection of skin outside of affected area reveals no abnormalities. Palpation of skin shows no abnormalities. Test Results: CPK isoenzymes - CK MM: 96% and CK MB: 8%. Test results received in house. Ordered total serum cholesterol. ECG shows a rate of 188 beats per minute, ST elevation and wide QRS. Impression: Acute MI of anterolateral wall, initial episode. Procedures: Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report. Oxygen saturation: 85 %. Plan: The following cardiac risk factor modifications are recommended: control blood pressure, quit smoking and take aspirin daily. Recommended CABG. The risks and benefits of the procedure were discussed in detail, including death, myocardial infarction, and stroke. Orders: Diagnostic & Lab Orders: Echocardiogram ordered. Ordered chest x-ray, two views - AP and lateral. Follow-up: Patient will be admitted to hospital today for acute MI. Prescriptions: nitrostat sublingual tablets Dosage: 0.4 mg tablet Sig: Use as Directed Dispense: 1 bottle Refills: 1 Allow Generic: Yes Patient Instructions: Patient given instructions on coronary artery bypass graft. Full Cardiologist, M.D. Digitally Signed on 02/10/2005 By: Full Cardiologist, M.D.
02/10/2005 Dr. Welby, M.D. 1025 Ashworth Road, Suite 222 West Des Moines, IA 50265 Dear Dr. Welby: Jane Doe was seen in my office for evaluation of chest pain following your initial referral. Thank you again for allowing me to participate in the care of your patients. In an attempt to provide your patients with quality patient care through improved communication, the following represents my notes from their last office visit: Impression: Acute MI of anterolateral wall, initial episode. Procedures: Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report. Oxygen saturation: 85 %. Plan: The following cardiac risk factor modifications are recommended: control blood pressure, quit smoking and take aspirin daily. Recommended CABG. The risks and benefits of the procedure were discussed in detail, including death, myocardial infarction, and stroke. Orders: Diagnostic & Lab Orders: Echocardiogram ordered. Ordered chest x-ray, two views - AP and lateral. Follow-up: Patient will be admitted to hospital today for acute MI. Prescriptions: nitrostat sublingual tablets Dosage: 0.4 mg tablet Sig: Use as Directed Dispense: 1 bottle Refills: 1 Allow Generic: Yes Patient Instructions: Patient given instructions on coronary artery bypass graft. I talked with Jane regarding her symptoms, risk factors, and abnormal stress test. I recommend that she undergo coronary angiography. The risks and benefits of the procedure were discussed in detail, including death, myocardial infarction, and stroke. Angioplasty and stenting were discussed and all questions were fully answered. Arrangements are being made for Kelley to have this performed next week. Thank you for referring this patient to me. Sincerely, Full Cardiologist, M.D. CC Dr. Jones
Patient Instructions for Jane Doe on 02/10/2005 What is a CABG? CABG stands for coronary artery bypass graft. During a coronary artery bypass, the diseased sections of your coronary arteries are bypassed with healthy artery or vein grafts to increase blood flow to the heart muscle tissue. These grafts are usually taken from vessels in your legs. How it's done: The surgeon will make an incision into your chest and prepare your heart for the graft. The graft is placed so it bypasses the diseased vessel and goes to the heart muscle tissue. After making sure the blood flow is normal, the incision is closed. What to expect after the procedure: You will spend about 2 days, depending on your recovery in the intensive care unit (ICU). While there, you may have a tube in to assist your breathing, continuous monitoring of your heart activity, a catheter to remove urine from your bladder, and tubes to help drain any chest fluid or stomach secretions. Once you come out of the ICU, you will be taken to a step-down unit for 3-8 days, depending on recovery time. When you are discharged to home, you will still have some therapy to undergo. This is a 4-6 week period. This includes physical therapy, occupational therapy and diet and exercise counseling. Your doctor will describe work/activity restrictions to you as well. Full Cardiologist, M.D. Provider: Full Cardiologist Patient: Jane Doe, Chart 3642 123 Main Street West Des Moines, IA 50265 Diagnoses Treatments Billing Statement - Thursday, February 10, 2005 1. 410.01 Acute Myocardial Infarction Of Anterolateral Wall, Initial Episode Of Care 1. 94760 Noninvasive Ear Or Pulse Oximetry For Oxygen Saturation; Single Determination 2. 93000 Electrocardiogram, Routine ECG With At Least 12 Leads; With Interpretation And Report 3. 82465 Cholesterol, Serum Or Whole Blood, Total Referring Physician: Dr. Smith Date Last Seen: 09/07/2004
Medical Clinic PRESCRIBER: A. Cardiologist, M.D. 1025 Ashworth Road, Suite 222 TELEPHONE: (515)327-8850 West Des Moines IA 50265 DEA: 123456789 ===================================================================================== PATIENT: Jane Doe TELEPHONE: 515-327-8854 ADDRESS: 123 Main Street DOB: 04/09/1973 West Des Moines, IA 50265 DATE: 02/08/2005 Rx nitrostat sublingual tablets, 0.4 mg tablet Disp: 1 bottle Sig: Use as directed Refills: 1 DISPENSE AS WRITTEN X GENERIC SUBSTITUTION PERMITTED SIGNATURE OF PRESCRIBER